question Flashcards
What are the available options for the treatment of diabetes?
The available options for the treatment of diabetes include sulfonylureas, DPP4 inhibitors/GLP1 analogues, SGLT2 inhibitors, and α-glucosidase inhibitors.
Why is pioglitazone contraindicated in heart failure patients?
Pioglitazone is contraindicated in heart failure patients as it worsens heart failure by stimulating sodium reabsorption from the collecting duct, leading to fluid retention.
Which DPP4 inhibitor has been shown to increase the risk of heart failure?
Saxagliptin has been shown to increase the risk of heart failure.
Do GLP1 analogues have a cardiovascular benefit?
GLP1 analogues have been shown to have a cardiovascular benefit, but limited data exists.
What is the dosing schedule and time of administration of sulfonylureas?
The dosing schedule and time of administration of sulfonylureas are as follows: Glibenclamide - 10-20 mg once or twice daily, 30 minutes prior to a meal; Glipizide - 20-40 mg twice daily, 30 minutes prior to a meal; Gliclazide - 160-320 mg twice daily, 30 minutes prior to a meal; Glimepiride - 4-8 mg once or twice daily, 30 minutes prior to a meal.
What is the time of administration for oral antidiabetic drugs?
The time of administration for oral antidiabetic drugs is as follows: Sulfonylureas - 30 minutes prior to a meal; Metformin - with or after meals; Acarbose/voglibose - just before major meals; Pioglitazone - before meals but at a fixed time; DPP4 inhibitors - prior to a meal; GLP1 agonists - prior to a meal.
What is the HbA1c-reducing efficacy of various treatment modalities in the management of diabetes?
The HbA1c-reducing efficacy of various treatment modalities in the management of diabetes is as follows: Lifestyle modification - 1-2%; Sulfonylureas (SU) - 1-1.5%; Metformin - 1-1.5%; SU+metformin - 1-1.5%; Pioglitazone - 1-1.2%; DPP4 inhibitors - 0.6-0.8%; GLP1 agonists - 1-1.3%; Insulin - unlimited.
What are the probabilities associated with sudden worsening of vision in a patient on metformin, sulfonylurea, and pioglitazone?
The sudden worsening of vision in a patient on metformin, sulfonylurea, and pioglitazone may be due to macular edema caused by pioglitazone. Other possibilities include retinal detachment, vitreous hemorrhage, and central retinal artery/vein occlusion.
Is there a real risk for bladder cancer with pioglitazone?
There is a possible association between bladder cancer and the use of pioglitazone. The risk of bladder cancer is higher with a cumulative dose >28g and duration of use >2 years. However, some studies did not reveal an increased risk with pioglitazone use.
What are some of the drugs available for the management of osteoporosis?
The available drugs for the management of osteoporosis are anabolic drugs (rPTH1-34 or rPTH1-84), calcilytics (CaSR), romosozumab (sclerostin), abaloparatide (rPTHrP1-34 analogue), estrogen and SERM, bisphosphonates, denosumab (RANKL antibody), odanacatib (cathepsin K inhibitor), and saracatinib (c-Src kinase inhibitor).
How do bisphosphonates act?
Bisphosphonates (BPs) bind to calcium hydroxyapatite at active bone remodeling sites to exert their antiresorptive effects. They inhibit crystal dissolution and suppress bone resorption by blocking osteoclast action. BPs are classified into non-nitrogen-containing BPs and nitrogen-containing BPs, with each having different mechanisms of action.
What is the mechanism of action of non-nitrogen-containing bisphosphonates?
Non-nitrogen-containing bisphosphonates, such as etidronate and clodronate analogues, are metabolically incorporated into non-hydrolyzable ATP analogues within osteoclasts, resulting in osteoclast apoptosis.
What is the mechanism of action of nitrogen-containing bisphosphonates?
Nitrogen-containing bisphosphonates (amino-BPs), like pamidronate, alendronate, risedronate, ibandronate, and zoledronate, inhibit the mevalonate pathway by blocking farnesyl diphosphate synthase (FDPS). This leads to cytoskeletal abnormalities and disruption of prenylation of small GTPases in osteoclasts, causing osteoclast apoptosis.
What are the precautions to be taken before administering bisphosphonates?
Before administering bisphosphonates, a detailed history, examination, and appropriate investigations should be conducted to rule out secondary causes of osteoporosis and establish a definite indication for bisphosphonate use. Vitamin D levels should be assessed and supplemented if deficient. Renal function should be assessed, and bisphosphonates should preferably be avoided if eGFR is <30 ml/min. Oral cavity should be examined for periodontal diseases/caries and treated before bisphosphonate therapy. Oral bisphosphonates should be avoided in those with upper gastrointestinal disease.
Which bisphosphonate is preferred for the management of osteoporosis?
Zoledronate is the most potent bisphosphonate and is administered once a year, making it convenient for patients in clinical practice. However, all newer generation bisphosphonates are equally effective in preventing both hip and spine fractures.
What adverse events are associated with bisphosphonate therapy?
The adverse events associated with bisphosphonate use include acute flu-like syndrome, GI intolerance (nausea, vomiting, diarrhea, esophagitis), hypocalcemia, hypophosphatemia, occasional atrial fibrillation, renal failure, severe suppression of bone turnover, atypical fractures, impaired bone remodeling, osteonecrosis of jaw, and rare cases of esophageal carcinoma.
How do bisphosphonates cause hypocalcemia and hypophosphatemia?
The exact mechanism of how bisphosphonates cause hypocalcemia and hypophosphatemia is not described in the course notes.
When is discontinuation of therapy mandated in the case of a rise in serum creatinine?
Discontinuation of therapy is mandated if the rise in serum creatinine is more than 30% or is associated with hyperkalemia.
What are the causes of worsening renal function after initiation of ACEIs/ARBs?
The causes of worsening renal function after initiation of ACEIs/ARBs include bilateral renal artery stenosis, overzealous use of diuretics, accelerated hypertension, and uncontrolled hyperglycemia.
How do ACEIs or ARBs prevent diabetes?
ACEIs/ARBs prevent new-onset diabetes by increasing skeletal muscle blood flow, upregulating IRS-2 mRNA expression, and inhibiting adipocyte RAAS. This leads to skeletal muscle vasodilatation, improved insulin delivery to muscle, increased IRS-2 mRNA expression, enhanced insulin signaling pathway, and differentiation of preadipocytes to smaller, more insulin-sensitive adipocytes.
What is the likely diagnosis for a 60-year-old male with T2DM presenting with acute-onset lumbar pain, haematuria, and history of passage of flakes in urine?
The likely diagnosis is acute papillary necrosis, which is indicated by the presence of necrosed papilla and the passage of flakes in urine. Common precipitating factors include urinary tract infections and drugs like NSAIDs. In patients with diabetes, factors such as accelerated atherosclerosis, increased angiotensin II, and vulnerability to urinary tract infections can predispose to papillary necrosis.
What are the modalities to preserve renal function in patients with DKD?
The modalities to preserve renal function in patients with DKD include good glycemic control (HbA1c <7%), optimal blood pressure control, use of ACEIs or ARBs, use of statins, correction of anemia, correction of metabolic acidosis, correction of secondary hyperparathyroidism, prevention of urinary tract infections, and the use of additional drugs like pioglitazone, linagliptin, and statins to reduce proteinuria.
What are the causes of hypertension in diabetes?
The causes of hypertension in diabetes include essential hypertension (in the majority of patients with T2DM), hyperinsulinemia/insulin resistance, diabetic kidney disease, renal artery stenosis, and autonomic neuropathy. Almost 50% of patients with T2DM are hypertensive at the time of diabetes diagnosis, and 80-90% of diabetics become hypertensive with the development of proteinuria.
How does insulin resistance cause hypertension?
Insulin resistance/hyperinsulinemia plays a role in the development of essential hypertension and T2DM. It increases blood pressure by promoting sodium and water reabsorption, enhancing intracellular movement of calcium, causing endothelial dysfunction, and reducing the vasodilatory effect of insulin in an insulin-resistant state.